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g + DV APPLICATION FOR PERMIT f SAN JOAQUiN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. —:7L30 Telephone (209) 466-6181 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED / ?3 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described: This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address --7S-.4itev]Z_ ,57W,.) Subdivision Name Owner's Name :Z—A:f,SS Address 54070 Phone Contractor's Name License No. XJrX7- Phone TYPE OF WELL/PUMP WORK: < NEW WELL ❑ WELL REPLACEMENT-[I]. DE, TRUCTIO.N O n- pa PUMP`INSTALLATION SYSTEM'REPAIR"" '�' �' `""OTHER U �"- A DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES ' AIR OSAL PLD. . PROP. LINE FOUNDATION AGRICULTURE-WELL WELL -- PITS/SUMPS INTENDED USE TYPE Industrial OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F U" I Open Bottom Manteca Dia. of Well Excavation # U Domestic/Private Gravel Pack r0 Tracy. ,,, Dia.,of Well C_a_sing,__ Public + Other Del to k Irrigation + 3 Type of Casing ation 1 Li 9 Approx. � Eastern Specifications � ' ❑Cathodic Protection Depth 5 Depth +-° , "' of Grout Seal 3 Geophysical . Other s y Type of Grout jJ I I � �rt Surface Seal Installed"bye' Repair Work Done F-1Typeof Pump' H:P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) r3._ Depth ! Filler Material (Below 501) ` TYPE OF SEPTIC WORK: NEW INST`ALLATION � REPAI_/ADDITION (_No_ -septic tank or seepage,pit.permitted if public sewer is I i available within 200 feet.) , Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size �Q Character of soil to a de th of 3 feet: dl-SA S/ _ ,Water. table depth SEPTIC TANK Cj�� e/Mfg Capacity No4,1 . mpartments PKG. TREATMENT PL,i.4� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM !l��// cI�--� Distance to nearest: Well Foundation Property Line DESTRUCTION U ; w LEACHING LINE No.]'&,Length-of lines—/•__- &-O .�.�..�»+Total-length/size ` -+ FILTER BED Distance to nearest: Well --~ Foundation f�z Property Line 7 SEEPAGE PITS Depth ,25-1 Size %_3,?3 � , . ^t Number SUMPS Distance to nearest: Well Foundation j Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in;such manner as to become subject to workmanS compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I .certify that in the performance of the work for which this permit is issued, I shall employ persons subject`to workman's compensation laws of California." The applicant must call for 11 required i pections. Complete drawing on reverse side. Signed X Title: �te* Date: �. FO PAR ENT USE y Application Accepted by Area CJ [ Stk 466-6781 n, Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date0 Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 " 10/82 500 14-26